Citizens Police Academy Form

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Application Information

First Name*

Last Name*

Address*

City

States

Zip Code

Phone Number*

Email Address

What do you hope to learn during this Academy?

Employment Information

Current Employer:

Address

City

State

Zip Code

Phone Number

Emergency Contact:

First Name

Last Name

Address

City

State

Zip Code

Phone Number*

Relationship:

How did you hear about the academy? ( Select all that apply)

Facebook (DPD/City)

Newspaper

Durham TV Network

National Night Out

Website (DPD/City)

Civilian Police Review Board

Partners Against Crime (PAC

Other:

Criminal History

Have you every been charged and/or convicted of a crime? *

Yes

No

If so, what year:

Drivers License:

Please List Information:

State Issued:

Tag#

State Tag Issued:

Medical Information (Optional)

List Allergies and Medications:

Physician:

Hospital Preference

Phone

Hospital

Initals: (Required)*

Consent:

I certify that the information in this application is true and complete to the best of my knowledge. I also grant permission for the Durham Police Department to verify the above information contained on this application and check for prior criminal history.
My initials below acknowledge that the above information is true and correct to the best of my knowledge.